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communication gap: provider --> insurance (or vice versa)

I'll start out by saying that I have my insurance through Humana, and it's a Medicare Advantage Plan. And I also apologize for the length of this post... just wanted to be thorough.

I am scheduled to have surgery to get Botox injections for my bladder. It sounds like it's a fairly common procedure/technique these days and as long as someone is a good candidate (meeting a few criteria... which I have for some time now), insurance companies have not been putting up much of a fight. Should be pretty easy... unless it's not.

I got a call from the person in my Dr's office who gets the authorizations from insurance and then schedules the surgeries. She was calling to inform me that she was able to get authorization for the procedure itself but not the actual Botox... or not entirely. She went on to explain that the Dr determined 300mg of Botox would be required, but the response they received from Humana stated that only 200mg was authorized. I asked her if she had any idea why they would do that or if it was a common occurrence, to which she answered 'no idea' and 'no'.

After a few days she called me back and said that the Dr said he'd do the procedure with the 200mg and 'see how it works'. This approach seems weird to me. I wasn't crazy about having to pay a surgery copay for something that was already not set up correctly from the start creating the potential for it not to be as effective as it could/should be... not to mention having to be knocked out and all the other life-disrupting, fun things that come along with surgery. But most of all what I couldn't understand was why Humana would only cover a portion of the Botox the Dr said was necessary. Why bother covering the surgery at all if they're not going to cover it being done properly? Or was my Dr incorrect in his assessment of the amount of Botox that would be required?

Now I'm at the phase where I start the arduous process of tracking someone down at Humana who can tell me why only 200 of the required 300mg of Botox were authorized. After dealing with agent after agent, I finally had someone transfer me to the Medication Intake department (or something close to that), who apparently give the authorizations. The person I spoke with told me that they do not authorize quantities of Botox; they only authorize its usage and state that as long as the Dr has deemed it medically necessary and it's within FDA guidelines, whatever quantity used will be covered. I explained that the Dr office is under the impression that only 200mg was authorized. Her response was that, no they misinterpreted the language used in the authorization letter, blah, blah, blah....

Back on the phone with the Dr office to relay to them what Humana said the letter meant. Of course this was not well-received and I was told that I was wrong, or making it up or not qualified to interpret Human's response.... So as of right now, they were going to do the surgery with two thirds of the required Botox or not at all. After a bit, I was finally able to get it out of the Dr office employee that they needed a new letter faxed to them with this clarification explicitly spelled out. Fair enough - I can make another call to Humana's Medication Intake department and have them fax over a letter with a bit of clarification.

Nope. The Humana employee explained to me that they do not have any control over the contents of the letter. They just enter some info into their computer and the letter itself is generated by the system and faxed to the appropriate person. I completely get that. I asked if there was an alternate letter template that could be used or if a follow-up letter could be sent manually or if Humana could at least talk on the phone to the Dr office so she could hear it direct from the source. The answer to all of these was NO, we can't do that, we don't do that, that won't work, etc, etc.... My last request was for the Humana employee to add the clarification that she had given me to the cover sheet of the fax she would re-send to the Dr office, to which she agreed. Yay.

Next I called the Dr office to let them know that our problem was solved. To my dismay, the additional clarification meant nothing to the Dr office. No real explanation - just frustration and being even more curt with me than in previous calls. I asked if she had any suggestions for how I could get Humana (who flat out said that the 300mg of Botox would be covered) to communicate in a sufficient manner to her that whatever quantity of Botox required (within FDA guidelines) would be covered so that I can have my procedure done properly. The response was something close to 'not my job'.

So I'm back to where I started - surgery with 2/3 of the required medication or no surgery at all.

Is anyone who is familiar with the system aware of some way I can get Humana to communicate this undisputed info to the Dr office in an acceptable manner? Or does anyone have any other suggestions for how to move forward? It just seems SO silly to me that, for once, Humana is actually covering everything they're supposed to, but the Dr office won't/can't accept this as being the case. And it is equally as silly to me that I may be stuck with a "watered down" version of a procedure that, when done properly (or at full strength), would be of tremendous benefit to me.

Have you spoken directly with the physician? I would recommend that. It sounds like his office staff may be creating this problem. I personally would not go ahead with the procedure for this lower dose. The procedure should be done properly, or not at all. You should also be able to get another letter from your insurance company. Did you speak to a supervisor or someone other than a clerk there? You should insist upon this. Good luck. A perfect example of how screwed up our health insurance system is in this country!

(KLD)

The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

Have you spoken directly with the physician? I would recommend that. It sounds like his office staff may be creating this problem. I personally would not go ahead with the procedure for this lower dose. The procedure should be done properly, or not at all. You should also be able to get another letter from your insurance company. Did you speak to a supervisor or someone other than a clerk there? You should insist upon this. Good luck. A perfect example of how screwed up our health insurance system is in this country!

(KLD)

Yup, I've had stuff like this happen all the time.

Don't have the procedure using the lesser amount. Talk with the doctor first. Let the doctor push her own staff to be more polite with you and willing to communicate again with the insurance company.

I have often called the insurance companies and asked to speak with supervisors until I find someone willing to go "on the record". Also, I ask them to do a 3 way call with me... calling the doctor's office... until everyone is on the same page. It can be challenging to get this to happen. Often insurance company folks just refuse, or hang up on me, or lie and say they can't do it etc..... So much wasted time. So much wasted money.

Every time you call the insurance company, and the doctor's office, document the date and time of the call and the name of who you are speaking to. Be polite, but firm. By getting people's names as soon as you start speaking with them, and using their name when you talk with them, it is more likely they will help you.... or at least not hang up on you. Ask to speak with supervisors when you hit a brick wall. And even supervisors have supervisors, so keep pushing it up if you need to.

And even that person in the doctor's office has a supervisor!

I would tell the doctor's office I would be willing to sign an ABN or similar document stating that I would be willing to pay for any additional cost for the higher Botox dose if insurance denied it. I would do this if I was fairly confident that it was going to paid for by the insurance based on my communications with them, but also make sure I would be willing to eat the cost... just in case. Regardless, I would appeal if they rejected it.

I want to thank everyone again for the advice and mostly for the reenforcement of my gut feeling that I should NOT have the procedure done without the full amount of Botox requested by the doc. In the future, asking to speak to supervisors and supervisors of supervisors will be my game plan (when appropriate). Fortunately, this time, I merely had to call the scheduling center, explain that I had been advised not to have the procedure done without the full 300mg (and that I was going to heed that advice) and that I would love to talk to the Dr and/or the department head to discuss rescheduling with everything done the right way. Magically, I received a call back from the scheduling center saying that they received the proper authorization from Humana and we can now move forward as planned. It sounds like the Dr office was trying to lay the blame on Humana. And Humana had been insisting all along that the people in the Dr office were not getting it right. As KLD suggested, I feel the people in the Dr office were creating the problem this time. But who knows - I am jst glad to have it all worked out - I go in next week.

To hhl's point (and I meant to make mention to this before), a polite and personable demeanor is the only way to go when trying to get anywhere within these giant bureaucracies (or even within your own doctor's office). It doesn't guarantee you better results but usually greatly reduces your odds of getting hung up on or lied to or passed off laterally. Besides, they are people too... sometimes unhelpful and bitter people but people all the same. Obviously there is a time and place for a more stern game - just have to keep in mind who you are talking to an when.

Just posting an update in case anyone arrived at this post looking for personal experience info on bladder Botox.... After all the nonsense with the coverage/authorization was cleared up, I got my injections (which was as simple as could be... even with having to be put under for that short time). It's been a little over 2 weeks, and I can't believe I was enduring what I was for as long as I was pre-Botox. The difference is night and day for me, with coming off 15mg of Ditropan/day being one of the greatest benefits. If your docs think you're a good candidate and your insurance will pay, I highly recommend.